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CSC GI Everolimus(28D:1-28) VER 8-15-17 (HL 4419)

CSC GI Everolimus(28D:1-28) VER 8-15-17 (HL 4419) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GI


CSC GI EVEROLIMUS(28D:1-28) VER: 8-15-17 –  Properties
Pre-Cycle –  8/3/2017 through 8/9/2017 (7 days), Planned
Day 1, Pre-Cycle –  Planned for 8/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Neuroendocrine Tumors (Advanced) and Carcinoid Tumors (Advanced); THERAPY: everolimus 10
mg by mouth daily continuously; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S Approximate, Expires: S+365, Routine
BUN
Expected: S Approximate, Expires: S+365, Routine
CREATININE
Expected: S Approximate, Expires: S+365, Routine
CALCIUM
Expected: S Approximate, Expires: S+365, Routine
LIPID PANEL
Expected: S Approximate, Expires: S+365, Routine
Patient should be fasting minimum 10 hours. The patient can only have water during the fasting period.
Cycle 1 –  8/10/2017 through 9/6/2017 (28 days), Planned
Day 1, Cycle 1 –  Planned for 8/10/2017
Treatment Plan Information
Reference Information (1)
PANCREATIC NEUROENDOCRINE TUMOR: Yao JC, et al. N Engl J Med. 2011;364(6):514-23.
Reference Information (2)
PANCREATIC NEUROENDOCRINE TUMOR: Yao JC, et al. J Clin Oncol. 2008;26(26):4311-8.
Reference Information (3)
CARCINOID TUMOR: Pavel M, et al. Lancet. 2011;378(9808):2005-12.
Treatment Plan Summary
DISEASE: Pancreatic Neuroendocrine Tumors (Advanced) and Carcinoid Tumors (Advanced); THERAPY: everolimus 10
mg by mouth daily continuously; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 1 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth
sores become severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): everolimus (dispensed Day 1 of
Cycle 1 only - subsequent refills will be ordered through the medication activity).
Take Home Medications
everolimus (AFINITOR) 10 MG tab
Take 1 tab by mouth one time daily., 10 mg, Disp-28 tab, R-0, 1 X DAILY starting S, Local Printer
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium.
Cycle 2 –  9/7/2017 through 10/4/2017 (28 days), Planned
Day 1, Cycle 2 –  Planned for 9/7/2017
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 2 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Neuroendocrine Tumors (Advanced) and Carcinoid Tumors (Advanced); THERAPY: everolimus 10
mg by mouth daily continuously; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth
sores become severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 3 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium.
Cycle 3 –  10/5/2017 through 11/1/2017 (28 days), Planned
Day 1, Cycle 3 –  Planned for 10/5/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Neuroendocrine Tumors (Advanced) and Carcinoid Tumors (Advanced); THERAPY: everolimus 10
mg by mouth daily continuously; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 4 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth
sores become severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium.
Cycle 4 –  11/2/2017 through 11/29/2017 (28 days), Planned
Day 1, Cycle 4 –  Planned for 11/2/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Neuroendocrine Tumors (Advanced) and Carcinoid Tumors (Advanced); THERAPY: everolimus 10
mg by mouth daily continuously; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 5 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth
sores become severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium.
Cycle 5 –  11/30/2017 through 12/27/2017 (28 days), Planned
Day 1, Cycle 5 –  Planned for 11/30/2017
Treatment Plan Information
Treatment Plan Summary
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 6 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

DISEASE: Pancreatic Neuroendocrine Tumors (Advanced) and Carcinoid Tumors (Advanced); THERAPY:
everolimus 10 mg by mouth daily continuously; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth
sores become severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 7 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Treatment Medications
Oral Chemotherapy Order Management
For this regimen, everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium.
Cycle 6 –  12/28/2017 through 1/24/2018 (28 days), Planned
Day 1, Cycle 6 –  Planned for 12/28/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Pancreatic Neuroendocrine Tumors (Advanced) and Carcinoid Tumors (Advanced); THERAPY: everolimus 10
mg by mouth daily continuously; CYCLE LENGTH: 28 days; COURSE: 6 cycles
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITH DIFFERENTIAL
Expected: S+28 Approximate, Expires: S+365, Routine
ELECTROLYTES
Expected: S+28 Approximate, Expires: S+365, Routine
GLUCOSE
Expected: S+28 Approximate, Expires: S+365, Routine
BUN
Expected: S+28 Approximate, Expires: S+365, Routine
CREATININE
Expected: S+28 Approximate, Expires: S+365, Routine
CALCIUM
Expected: S+28 Approximate, Expires: S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC with DIFF.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than 1,000/µL or Platelets less than 75K/µL.
Nursing Procedure, Assessment and Monitoring
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 8 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org

Patient Instructions(1)
Stomatitis is a common side effect of everolimus. Educate patient on the importance of good oral hygiene. If mouth
sores become severe, contact the clinic.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin lock flush 10 UNIT/ML injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Treatment Medications
Oral Chemotherapy Order Management
For this regimen, everolimus will be ordered through the medication activity after the initial order.
Follow-Up
DAY 29 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC with DIFF, Electrolytes, Glucose,
BUN, Creatinine, Calcium.
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Zztestonc,Jeff J [2507481]
8/10/2017 8:50:03 AM Page 9 of 9
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 08/2017CCKM@uwhealth.org